The Role Of Pinning In Subcapital Fractures Presented by: Dr.Abdulrahman Algarni

Choice of treatment modality :ease of surgery,cost,morbidity and mortality,risk of AVN,reoperation rate and functional disability

Young pt : IF with 3 or 4 screws is accepted therapy Young pt : IF with 3 or 4 screws is accepted therapy. Capsulotomy does not seem to be clinically relevant. Expedient surgery : probably low AVN rate.Also,only 20% require further surgery.

Some data suggest that urgent reduction and IF within 12 hrs may be associated with reduced rate of AVN.

Is there a place for IF in the elderly pt ? In general , arthroplasty led to fewer treatment failure, better function but more complications.Mortality rates : did not differ.

In one long F/U prospective cohorts study : both IF and HA results in poor outcome with respect to pain and mobility with 20% revision rate and no difference mortality or function.

IF: fewer postop. Complication,shorter hospital stay,reduced cost and higher reop. rate. Other studies : higher reop.rate for IF but also higher than expected for arthroplasty.

IF is the optimal treatment for bedridden or demented Pt for pain relief.Dislocation rate is 32% with mental dysfunction for HA Vs 12% in mentally normal Pts.

Why does young high demand Pt do better with IF? Nutrition status,ability to use crutches and bone quality. All prospective RCTs have not discuss efficacy of fracture reduction. Comminuted fractures are difficult to reduce and more prone to failure.

conclusion IF is currently the treatment of choice for displaced subcapital femoral neck fractures if the Pt is young,demented or if the fracture can be reduced anatomically and fixed in a timely and structurally stable manner in the elderly Pt.

The unipolar endoprosthesis for hip fractures:is it the best solution? The optimal choice:minimize mortality ,pain ,bleed,hospital stay, revision rate , cost and maximaize function.

1)Should i fix (IF) or replace the head (arthroplasty) Arthroplasty (uni-,bi-,or THR):lower revision rate while decreased OR time ,blood loss and mortality for IF.

Which arthroplasty should I use? Limited number of RCTcomparing implants Uni- Vs bi :no difference . Uni- Vs THR : few trials, small samples . Bi- Vs THR : high surviorship for all.

Should I cement the stem? Intraop. Hypotension related to arthroplasty has been described for both cemented and uncemented implants . One review :parker et al, 4 RCTs. Cemented :low risk of postop pain at 1 Year, low risk of failure to regain mobility .

No other outcomes could be measured second review studies are of poor quality. Another study linked the risk of clinical complications to high preop PAP(>30mm Hg).

What about these new unipoalr implants ? No comparative study that measure clinical or economical out comes between new unipolar and the classic ones.

summary Certain parameters such as revision rate would guide surgeon toward arthroplasty over IF. Limited information is available to guide surgeon to the best implant if arthroplasty is chosen and more trials are needed .

The safe use of cement is still debated The safe use of cement is still debated. Limiting its use to patients who do not have history or signs of severe cardiorespiratory disease and who are well hydrated is recommended.